Jan. 31, 2012 -- Postmenopausal women with a history of
smoking who take heartburn drugs called proton pump inhibitors (PPIs) for two years or longer may be more likely to sustain a hip fracture.

And the longer women take PPIs, the greater their risk.

That said, the risk does disappear after women stop taking these drugs for two years. The new findings appear in the journal BMJ.

These drugs, which are available by prescription and over the counter, work by reducing the secretion of stomach acid. PPIs such as Nexium, Prevacid, Prilosec, and Protonix are commonly recommended for people with gastroesophageal reflux disease (GERD), peptic ulcers, erosive esophagitis, and a precancerous condition known as Barrett's esophagus. They are among the most widely used medications worldwide.

Changing the acid environment in the stomach may reduce the absorption of calcium, which is needed for healthy bones. This is not the first study to link long-term PPI use with bone fractures, but it does help narrow down who is at greatest risk. Women who never smoked were not at increased risk for hip fracture even if they took PPIs regularly, the study showed.

The message is clear: Postmenopausal women with history of smoking who take PPIs for longer than two years have more than a 50% chance of sustaining a hip fracture, says researcher Hamed Khalili, MD. He is a gastroenterologist at Massachusetts General Hospital in Boston.

It is also time to take a long, hard look at who is taking these pills chronically and why. "There are very few indications that require long-term and regular use of PPIs," he says.

His advice? "Consider stopping if there are no real indications, and among those that require long-term use, you may try to switch to less potent acid-suppressive medications."

Make Lifestyle Changes First

Robynne Chutkan, MD, says these medications must be used judiciously, not indiscriminately. She is an assistant professor of medicine at Georgetown University Hospital in Washington, D.C.

We may all want to pop a pill and make our heartburn go away, but "the cornerstone treatment for GERD is still lifestyle modifications."

This includes:

Decreasing or eliminating caffeine and alcohol

Quitting smoking

Not eating late at night

Avoiding your personal heartburn triggers

Losing weight, if necessary

"These drugs are so effective that people are less compelled to change their habits, but their use comes with a price -- fracture risk," she says. They are good drugs and are relatively safe, but for most people there is a lifestyle alternative.

Women should ask themselves and their doctors two questions about PPIs: "Do I need it and do I need it long term?" Some people do require long-term use of these medications, Chutkan says.

Ethel S. Siris, MD, agrees that long-term PPI use is another risk factor for fractures, especially in women with a history of smoking. She is the Madeline C. Stabile Professor of Clinical Medicine and the director of the Toni Stabile Osteoporosis Center at Columbia University Medical Center in New York. "The bottom line is that this is one more risk factor that you have to work around," she says.

It is important to know your risk for fractures and get bone density scans when appropriate. If you are at risk, the same rules apply to everyone. This includes making sure you get enough calcium and vitamin D, exercising regularly, and stopping smoking. "If the woman has already had a fracture, it is time to consider medication to prevent repeat fractures," Siris says.